Surgical treatment of anaplastic thyroid carcinoma. Our experience.

BACKGROUND: In anaplastic thyroid carcinoma (ATC) surgical resection associated to radiotherapy and chemotherapy can ameliorate local disease control with occasional long-term survivals. PATIENTS AND METHODS: Resection of the tumor was accomplished in 20 ATC patients, with no macroscopic (13 cases) or minimal residual neck disease infiltrating vital structures (7 cases). Ten of these patients (50%) had distant metastases. Sixteen cases were also treated with radiotherapy and chemotherapy, while in one patient only chemotherapy was possible; 2 patients refused further therapy; the last one is starting adjuvant treatment. Morbidity and survival were analysed, and compared with other 15 ATCs submitted to partial tumor debulking or not operated at all (control group). RESULTS: Function of at least one laryngeal recurrent nerve was preserved in all 20 patients; none experienced permanent hypoparathyroidism. At last follow-up examination 17 patients had died and 3 were alive 1, 6 and 80 months after the operation, the latter being free of disease. Survival of dead patients ranged from 3 to 28 months (mean: 8 months). In the control group all patients died, survival ranging from 1 to 13 months (mean: 4 months). Actuarial analysis of survival showed a significant difference between the two groups (p = 0.0112); multivariate analysis of several prognostic factors confirmed that complete or near complete tumour resection was the most relevant. CONCLUSIONS: Surgical resection is an important component of the multimodal treatment of ATC and should be attempted whenever possible.

Is central neck dissection a safe procedure in the treatment of papillary thyroid cancer? Our experience.

BACKGROUND AND AIMS: The role of central neck dissection in the treatment of papillary thyroid carcinoma is debated. This retrospective investigation was undertaken to assess whether it augments total thyroidectomy morbidity. PATIENTS/METHODS: A total of 305 consecutive patients who had undergone total thyroidectomy for papillary thyroid carcinoma were divided into three groups: group A (n = 64) showed evidence of node metastases and received therapeutic bilateral central node dissection; group B (n = 93) showed negative nodes and received prophylactic ipsilateral central node dissection; group C (n = 148) showed negative nodes and received total thyroidectomy alone. The rates of transient and permanent complications within the three groups were compared. RESULTS: Histopathological examination detected node metastases in 46 (72%) group A patients and in 20 (21%) group B patients. Parathyroid autotransplantation was carried out in 41 (64%) patients in group A, 55 (59%) in group B, and 43 (29%) in group C (P < 0.001). One or more parathyroid glands were found in 20% of the specimens from group A, 11% of those from group B, and 9% of those from group C. None of the patients in either group A or group B reported permanent laryngeal recurrent nerve paralysis, but two (1.3%) in group C did. Transient laryngeal recurrent nerve paralysis occurred most often in group A patients (7.8% versus 5.4% versus 1.3%, respectively) and was bilateral in two patients (one in group A and one in group B). None of the patients in either group A or group B developed permanent hypoparathyroidism, but four (2.7%) in group C did. Transient hypoparathyroidism was highest in group A patients (31% versus 27% versus 13%, respectively; P = 0.003). Postoperative bleeding requiring reoperation occurred in one group B patient and in two group C patients. CONCLUSIONS: Central neck dissection did not increase permanent morbidity and revealed a significant rate of nonclinically evident node metastases. In experienced hands, central neck dissection should be routinely combined with total thyroidectomy in the primary treatment of pre- or intraoperatively diagnosed papillary thyroid cancer. When no macroscopic evidence of metastasis is present, ipsilateral central neck dissection is the best treatment strategy in a balanced decision between the need for achieving local radical excision, correct disease staging, and reducing the risk of complications.

[Post-thyroidectomy cervical hematoma]. / L'ematoma cervicale postoperatorio nella chirurgia tiroidea.

AIM: Postoperative hematoma is a complications of thyroid surgery uncommon but potentially life threatening. It has implications for the trend toward outpatient procedures. METHODS: Retrospective review of 1.221 thyroidectomies performed at our institution over a 6-years period, to identify patients with hematomas requiring reoperation. Symptoms, treatment and findings at reoperation were evaluated. A control group (n=120) was compared for perioperative risk factors and outcome. RESULTS: Eighteen patients (1.5%) developed a postoperative hematoma. Symptoms included neck pain/pressure in 10 patients, respiratory distress in 9, wound drainage in 2, dysphagia in 1, agitation and sweating in 1. Mean time to symptom onset was 12 hours (range: 1.3-40 hours). Six hematomas presented between 7 and 24 hours, and 3 beyond 24 hours. Six patients required bedside hematoma evacuation. The bleeding source was identified in 15 patients. All patients recovered well, but one required a temporary tracheostomy. Case/controls comparison yielded in the study group a higher prevalence of hyperthyroidism (55.6% vs 25.8%, P=0.022) and intrathoracic goiter (50% vs 22.5%, P=0.029), and a longer mean hospital stay (5.22 vs 4.1, P=0.012); morbidity was not increased. CONCLUSIONS: Postoperative hematoma is an uncommon complication of thyroid surgery. If treated promptly, serious consequences can be avoided. The relatively long interval between the initial operation and the hematoma development needs to be considered when establishing outpatient practice guidelines.

[Surgical treatment of Graves' disease: results in 108 patients]. / Trattamento chirurgico del morbo di basedow: risultati in 108 pazienti.

AIM OF THE STUDY: To evaluate morbidity and functional results of surgical treatment in patients with Graves' disease. METHODS: A retrospective study was performed in 108 patients operated on during 1993-2003. Main indications for surgery were failure of treatment with antithyroid drugs (80.6%), large goiter (46.3%) and/or severe ophthalmopathy (23.1%). Surgical procedures were extensive subtotal thyroidectomy (EST; n = 33; uni- or bilateral remnant of <2 g) or total thyroidectomy (TT; n=75). Functional results were established in 89 patients (27 EST patients and 62 TT patients) after a mean follow-up of 5.9 years. RESULTS: Operative mortality was zero. There were 4 (3.7%) transient unilateral recurrent laryngeal nerve (RLN) palsies and no cases of permanent RLN palsy. Temporary hypocalcemia occurred in 15 patients (13.9%) and permanent hypoparathyroidism resulted in two (1.9%). Four patients (3.7%) developed a postoperative hematoma that required reoperation. There was no significant difference in the rate of complications between EST and TT, although temporary hypocalcemia was more common following TT than EST (17.3% vs. 6.1%) and permanent hypoparathyroidism affected only TT patients. None of the patients developed recurrent hyperthyroidism; all patients are maintained on levothyroxine. CONCLUSIONS: Surgery is an effective therapy for selected cases of Graves' disease. When performed by experienced surgeons, it can be carried out with no mortality and minimal morbidity. EST (with uni- or bilateral remnant of <2 g) and TT are both effective in order to achieve a definitive cure of hyperthyroidism.

Oxidative damage and transforming growth factor beta 1 expression in pretumoral and tumoral lesions of human intestine.

The aim of this study was to evaluate a possible relationship between oxidative stress and transforming growth factor beta 1 (TGF beta 1) expression in human colon adenocarcinoma. Crohn's disease, an inflammatory pathology of the intestine often regarded to as precancerous, was also examined. Indices of impaired redox balance were monitored in blood and in bioptic samples from 10 adult patients with adenocarcinoma of the colon and from five patients with Crohn's disease. On tissue samples TGF beta 1 mRNA expression was also determined. Ten healthy adults provided normal reference values for plasma indices of oxidative stress, and normal tissue distant from the lesions was used for comparative analysis. Fluorescent adducts with plasma proteins of malonaldehyde (MDA) and 4-hydroxynonenal (HNE) were significantly lower than controls in the plasma from cancer patients and significantly higher in the plasma from Crohn's patients. In adenocarcinoma biopsies, susceptibility to lipid peroxidation processes and TGF beta 1 expression were below the relative control; in Crohn's disease, lipid peroxidation and cytokine expression were both above the relative control. The findings obtained suggest the existence of an association between oxidative damage and fibrogenic cytokine expression in the human intestine. Further studies are needed to conclusively prove the correlation between the two events.

[The surgical approach to adrenal incidentaloma]. / L'approccio chirurgico all'incidentaloma surrenalico.

In this paper the Authors analyse the indications for treatment of adrenal incidentaloma by making a retrospective review of this series. These indications are compared with recent trends which have emerged in the literature.

[Instrumental follow-up of patients treated by internal biliary drainage]. / Il follow-up strumentale dei pazienti trattati con drenaggio biliare interno.

The various radiological techniques available for the long-term follow-up of patients given definitive percutaneous trans-hepatic biliary implants (DTBI) are evaluated on the basis of personal experience. After a rapid examination of the available technics it is concluded that direct X-ray, echotomography and sequential hepatobiliary scintigraphy are more than sufficient for an accurate follow-up of the disease in such patients.

[Immune complex monitoring in Echinococcus infections]. / Monitoraggio degli immunocomplessi nell'affezione echinococcica.

In two patients with hepatic echinococcosis, we studied the in vivo interaction between circulating immune complexes and polymorphonuclear neutrophil surface receptors according to our previously described technique and quantitated the amount of circulating immune complexes by the C1q binding assay. Both tests were positive prior to surgical removal of the cysts, to gradually become negative to weeks later, and are persistently negative at two months after complete asportation. The application of the two tests may be of value in assessing surgical radicality and consequently the prompt disappearance of circulating parasite antigens. In particular, failure of these two tests two turn negative or the occurrence of further, new positivities may suggest either uncomplete eradication of the cyst or reinfection. These immunologic techniques appear to provide a better monitoring of echinococcosis than all the other well-known immunological tests which detect specific immunoglobulins present in serum for a long time and therefore unable to indicate the persistence or the new appearance of the parasite antigens.

[Surgical treatment of endocrine tumors of the pancreas]. / Il trattamento chirurgico dei tumori endocrini del pancreas.

Following a brief review of the literature dealing with the rarity of this disease, and the diagnostic progress made to date, the surgical techniques applicable to the various locations of the neoplasia are described. Personal experience with 8 insuloma patients is reported.

[Diagnosis of primary and secondary tumors of the liver]. / La diagnosi dei tumori primitivi e secondari del fegato

A brief epidemiological and clinical introduction is followed by an examination of the most useful methods for the diagnosis of primary and secondary tumours of the liver: alpha protein values, scintiscanning, arteriography of the coeliac artery, splenoportography, and laparotomy with directed biopsy. The diagnostic specificity and percent positivity of each method are illustrated.

[Current role of abdomino-perineal amputation]. / Ruolo attuale dell'amputazione addomino-perineale.

In Italy 6.5% of cancer deaths can be attributed to localized colorectal cancer of which rectal cancer alone accounts for 33%. The introduction of mechanical staplers and new techniques (colo-anal anastomosis) into colon surgery has led to a drastic reduction in indications for Miles' operation in favour of techniques which aim to conserve the sphincter. From October 1987 to March 1991 the Surgical Clinical of the Ospedale Maggiore in Novara operated 75 patients with rectal cancer. Twenty-eight patients underwent APA (abdominoperineal amputation) whereas 47 underwent conservative surgery, referred to as SSR (sphincter-saving resection). Of the 28 APA patients, 19 revealed a localisation in the lower rectum (0-5), 7 in the mid rectum (6-8) and 2 in the upper rectum (9-15). In the latter two cases the considerable size of the tumour mass and the extraparietal diffusion of the tumour led the authors to prefer APA rather than SSR. In SSR the minimum distal safety margin from the tumour was 2 cm, whereas the mean distance of the tumour from the anal margin in APP patients was 4 cm, and that in SSR patients 11 cm. The stage of cancer was not taken into consideration when choosing the type of surgery. Postoperative mortality was 3.5% for APA and 2% for SSR. The overall incidence of recidivation was 20%, equivalent to 11 patients. Recidivation was found to be more frequent in the lower rectum (6 cases) compared to the upper rectum (1 case).(ABSTRACT TRUNCATED AT 250 WORDS)

[Transverse mesocolon herniation. Description of a clinical case]. / Ernia trans-mesocolica. Descrizione di un caso clinico.

A case of herniation of small bowel through a defect of the transverse meso-colon with secondary herniation through the gastrocolic ligament and re-entry into the greater peritoneal cavity is reported. This form of lesser sac hernia is rare and only one hundred half cases have been reported in literature.

[The autologous splenic reimplant in the rat]. / Reimpianto splenico autologo nel ratto.

In order to evaluate the clinical utility of autologous splenic transplantation in the omental pouch, a pneumococcal challenge was performed in 3 groups of rats, after demonstration of vitality of the intraperitoneal inoculum: Group A: splenectomized rats; Group B: reimplanted rats; Group C: sham operation. No statistically significant difference was found between the first two groups regarding resistance against infection (p less than 0.982), while normal rats proved more resistant (p less than 0.031). Between group A and B significant differences (p less than 0.001) exists only for a more precocious mortality in the first group. The poor clinical utility of the technique is demonstrated.

[Gastric surgery in morbid obesity. Apropos of 101 cases]. / Chirurgie gastrique dans l'obésité morbide. A propos de 101 cas.

The authors analyze the complications and the results of gastric surgery for morbid obesity, on the basis of their personal experience. After abandoning up jejunoileal by-pass because of its severe complications, they started to perform gastric by-pass and vertical banded gastroplasty according to Mason. The number of severe complications was low and the results on the weight loss were good, without any disturbance of metabolic and nutritional tests. Gastric by-passes and gastroplasties had similar results. The authors suggest that gastroplasty could be the technique of choice as it is a simple and quick operation, without anastomosis, which ensures a better respect of gastroduodenal physiology and the possibility of exploration of the distal gastric pouch.

Primary hyperparathyroidism sustained by a giant adenoma of the parathyroid gland.

A case of primary hyperparathyroidism sustained by an unusually large parathyroid adenoma is presented. The tumor affected a 45-year-old woman with a 15-year history of nephrolithiasis and presented as a palpable neck mass. On the basis of clinical findings and ultrasound examination, it was initially misdiagnosed as a thyroid nodule. CT scan and transesophageal endosonography gave a correct definition of the tumor, which was located behind the left thyroid lobe and expanded posterior to the pharynx and the esophagus in the prevertebral space. At surgery a parathyroid tumor measuring 8 x 7 x 3 cm and weighing 90 g was successfully removed. No signs of malignancy were observed by both morphological and cell kinetic analyses.